DIRECT BANK CREDIT [DBC] FORM

To
The Incentive cell Department
Star Health and Allied insurance Co. Ltd.
Corporate office - Chennai

I request you to credit my Commission / Incentive to the Bank account as stated below.
(Please fill the form in Block Letters only)
Beneficiary Code:
(will be filled up by the Corporate Office)

Beneficiary Name :
Branch Name : Office Code :

BENEFICIARY NAME
(As per the Bank Account) :

BANK NAME :

BANK BRANCH NAME :

BANK BRANCH ADDRESS :

P I N C O D E

FULL BANK ACCOUNT NUMBER :

IFSC CODE OF BANK BRANCH :

BENEFICIARY PAN NUMBER :

BENEFICIARY E-MAIL ID :

BENEFICIARY MOBILE NUMBER :

I hereby declare that the particulars given above are true and complete.

Date Signature of the Beneficiary

Note -Please attach the scan copy of canceled Cheque leaf/Bank passbook/Bank Statement.

The above details mentioned by the beneficiary Mr/Mrs/Ms.........................................................................................................with the

business code/employee ID...........................................has been duly verified and found to be correct.

Name of the verifying officer :

Designation :

Date :

Signature with office seal